Date
Employee Name:
Date of Birth:
Position applying for:
If Aide, current certificate
Has caller ever worked in home care?
If yes, where
Is caller currently working anywhere?
If yes, where
If yes, when could they be available to do orientation?
AGENCY POLICY: we cannot hire individuals with convictions listed as unemployable by the state. Would anything be likely to show up on their Criminal History check to prevent us from hiring?
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PRE-HIRE CHECKS
Employee:
Social Security #:
Employment Application
Availability: check all that you could work
Availability
Mon
Tues
Weds
Thurs
Fri
Sat
Sun
Day hours
Evening hours (5-9 P)
nights (9 P-12 MN)
overnights
live-in
Date of Application:
-
Month
-
Day
Year
Date
Date Available for Employment:
-
Month
-
Day
Year
Date
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number or
Format: (000) 000-0000.
Email address
example@example.com
Language skills other than English (written/spoken)
Are you legally eligible for employment in the US?
Yes
No
If not legal citizen: Do you have a green card?
Yes
No
Do you have a social security card?
Yes
No
Has your visa expired?
Yes
No
REFERRAL INFORMATION
How did you hear about us? (Please check)
Which site?
Current Employee
We'd like to thank them
Other
EMERGENCY CONTACT INFORMATION - Please Print Clearly
Name:
Relationship:
Cell Phone Number:
Format: (000) 000-0000.
an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status.
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Employment History - Please begin with your most recent or current place of employment.
Place of Employment:
Start Date:
-
Month
-
Day
Year
Date
Address:
End Date:
-
Month
-
Day
Year
Date
Position:
Phone Number:
Format: (000) 000-0000.
Supervisor:
Salary:
Reason for Leaving:
Final Salary:
Place of Employment:
Start Date:
-
Month
-
Day
Year
Date
Address:
End Date:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Start Date:
-
Month
-
Day
Year
Date
Education
High School:
College:
Other:
Other:
Military Service
Branch of Service:
Dates of Service:
Highest Rank Achieved:
Currently in a Reserve Unit?
Yes
No
Special Schooling and/or Duties:
Licenses and Certifications
Licenses and Certifications
Rows
License or certificate
ID number
Expiration date
2.
3.
Criminal History- By my signature below, I acknowledge/consent to a criminal check on my name. Have you ever been convicted of violating any law? (Please omit minor traffic violations.)
Have you ever been convicted of violating any law?
Yes
No
if yes, please list conviction(s), date(s) and location(s). The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate and do all required background/registry checks that are required for consideration for employment at the agency.
Employee Candidate Signature
Date
-
Month
-
Day
Year
Date
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Reference Form #1
Company Name:
Address:
Phone:
The position being applied for is:
Applicant's Authorization to Release Information
I hereby give permission for my previous employer to release this referral information about my position with their company and comments regarding my work ethic and character while in their employ.
Applicant's Signature
Date of signature
-
Month
-
Day
Year
Date
THIS SECTION TO BE COMPLETED BY PERSON COMPLETING THIS REFERENCE
Employment Dates: From
to
Position:
Reason for separation:
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